Cra

ckin

g th

e C

ode

Alp

habe

t So

up:

Und

erst

andi

ng t

he

Use

of

Cod

ing/

Bill

ing

Term

inol

ogy

Jane

V. W

hite

, PhD

, RD

, LD

N, F

AND

Em

eritu

s Pr

ofes

sor,

Fam

ily M

edic

ine

Uni

vers

ity o

f Te

nnes

see

– Kn

oxvi

lle

Chai

r, Ac

adem

y Co

ding

Sur

vey

Met

hodo

logy

Tas

k Fo

rce

Aca

dem

y Re

pres

enta

tive:

AM

A RU

C H

CPAC

Sand

i Mor

ris, R

D,C

D

Indi

ana

Uni

vers

ity H

ealth

-Gos

hen

Hos

pita

l Cl

inic

al N

utrit

ion

Man

ager

IA

ND

Rei

mbu

rsem

ent

Repr

esen

tativ

e

2

Dis

clos

ures

We

have

no

com

mer

cial

rel

atio

nshi

ps t

o di

sclo

se r

elev

ant

to t

he t

opic

bei

ng

pres

ente

d.

Sess

ion

Obj

ectiv

es

•Id

entif

y pr

oced

ure

code

s fo

r nu

triti

on a

nd n

utrit

ion-

rela

ted

serv

ices

tha

t m

ay b

e re

imbu

rsed

by

Med

icar

e an

d/or

com

mer

cial

thi

rd p

arty

pay

ers.

•

Und

erst

and

the

term

s fo

und

on a

typ

ical

cla

ims

form

an

d th

e pr

oper

pro

cedu

re fo

r su

bmitt

ing

a “c

lean

” cl

aim

.

•Re

cogn

ize

oppo

rtun

ities

to

expa

nd n

utrit

ion

prac

tice

to

rece

ive

paym

ent

for

nutr

ition

and

nut

ritio

n-re

late

d se

rvic

es in

mul

tiple

set

tings

.

•Re

cogn

ize

new

too

ls a

nd r

esou

rces

incl

uded

on

the

Acad

emy’

s w

ebsi

te t

o he

lp e

duca

te R

DN

s on

thi

s to

pic.

•Re

cogn

ize

codi

ng u

se a

nd p

aym

ent

tren

ds a

mon

g RD

Ns

acro

ss t

he c

ount

ry.

4

Beck

y Su

lik, R

D, C

DE,

LD

- C

hair

Luci

lle B

esel

er, M

S, R

D, C

DE,

LD

N -

Vic

e-Ch

air

Amy

Dav

is, R

D, L

RD

Den

ice

Ferk

o-Ad

ams,

MPH

, RD

N, L

DN

Lo

rri H

olzb

erg,

MA,

RD

N

Ingr

id K

nigh

t, R

D

Alex

is P

ezzu

llo, M

PH, R

D, L

DN

Ex

-Offi

cio:

•

Keith

Ayo

ob, E

dD, R

D, C

D/N

, FAD

A (C

PT P

anel

Rep

) •

Jane

Whi

te, P

hD, R

D, L

DN

, FAN

D (

RUC

Pane

l Rep

) St

aff:

•

Mar

sha

Scho

field

, MS,

RD

, LD

N, F

AND

•

Mar

a Bu

jnow

ski,

MAE

d, R

D, L

D

Acad

emy

Nut

ritio

n Se

rvic

es P

aym

ent

Com

mitt

ee (

NSP

C)

NSP

C Pu

rpos

e/M

embe

r Be

nefit

s

Mem

ber E

duca

tion

Deve

lop,

impl

emen

t and

mar

ket

a m

ulti-

face

ted

mem

ber

educ

atio

n pl

an th

at a

ddre

sses

va

rious

pra

ctic

e se

ttin

gs, l

evel

s of

mem

ber e

xper

tise

and

curr

ent a

nd fu

ture

pay

men

t m

odel

s..

Advo

cacy

In

crea

se R

DN re

cogn

ition

and

co

vera

ge fo

r RDN

serv

ices

.

Cod

e Cr

eatio

n/Va

luat

ion

Deve

lop

prop

osal

s to

deci

sion

mak

ers t

hat e

xpan

d th

e ra

nge

of

serv

ices

that

can

be re

imbu

rsed

an

d re

port

ed b

y RD

Ns.

Colla

bora

tion

or In

fluen

ce

Advi

se a

nd c

olla

bora

te w

ith

Acad

emy

orga

niza

tiona

l uni

ts to

ac

hiev

e Co

mm

ittee

's go

als.

Nat

iona

l/Gra

ssro

ots

Publ

ic P

ayer

s/Pr

ivat

e Pa

yers

Intr

oduc

tory

Ter

ms

& A

cron

yms

AM

A:

Amer

ican

Med

ical

Ass

ocia

tion

CP

T: C

urre

nt P

roce

dura

l Ter

min

olog

y Pa

nel

•Co

de C

reat

ion

Pane

l � �

� S

ervi

ces

Des

crip

tors

R

UC

: RV

S U

pdat

e Co

mm

ittee

•

Code

Val

uatio

n Pa

nel �

� �

Pay

men

t R

VS:

Res

ourc

e-Ba

sed

Rela

tive

Valu

e Sy

stem

H

CP

AC

: H

ealth

Car

e Pr

ofes

sion

als

Advi

sory

Co

mm

ittee

(no

n-ph

ysic

ian

pane

l) N

CP

T: A

cade

my

deve

lope

d st

anda

rdiz

ed la

ngua

ge u

sed

to d

escr

ibe

the

Nut

ritio

n Ca

re P

roce

ss;

used

in t

he

docu

men

tatio

n of

nut

ritio

n se

rvic

es p

rovi

sion

•

does

not

rep

lace

ICD

-9 d

iagn

osis

Basi

c Te

rms

and

Acro

nym

s

CM

S: C

ente

rs fo

r M

edic

are

& M

edic

aid

Serv

ices

M

edic

are

• P

art

A:

Hos

pita

l ser

vice

s •

Par

t B

: O

utpa

tient

pro

fess

iona

l ser

vice

s (M

NT)

, D

iagn

ostic

tes

ts/L

ab, e

tc.

• Par

t C

: M

C Ad

vant

age

Plan

s • P

art

D:

Pres

crip

tion

drug

s H

IPA

A:

Hea

lth I

nsur

ance

Por

tabi

lity

& A

ccou

ntab

ility

Act

N

PI:

Nat

iona

l Pro

vide

r Id

entif

ier

Cre

dent

ialin

g: a

sys

tem

atic

app

roac

h to

the

col

lect

ion

and

verif

icat

ion

of p

rofe

ssio

nal q

ualif

icat

ions

Nat

iona

l Pro

vide

r Id

entif

ier

(NPI

)

•A

10-d

igit

num

ber

used

to

reco

gniz

e th

e pr

ovid

er o

n cl

aim

s tr

ansa

ctio

ns.

•

All p

rovi

ders

who

bill

3rd p

arty

pay

ers

mus

t ha

ve o

ne (

HIP

AA r

equi

rem

ent)

•La

sts

inde

finite

ly;

does

NO

T co

ntai

n “i

ntel

ligen

ce”

•

Each

pro

vide

r ge

ts O

NE

NPI

, reg

ardl

ess

of t

he n

umbe

r of

pra

ctic

e of

fices

.

•G

roup

pra

ctic

es, h

ospi

tals

, and

cor

pora

tions

get

an

NPI

(se

e CM

S M

edle

arn

artic

le:

http

://w

ww

.cm

s.hh

s.go

v/M

edic

areP

rovi

derS

upEn

roll/

dow

nloa

ds/E

nrol

lmen

tShe

et_W

WW

WH

.pdf

•Co

ntac

t th

e N

atio

nal P

lan

& P

rovi

der

Enum

erat

ion

Syst

em N

OW

! •

Appl

y ov

er t

he W

eb:

http

s://

nppe

s.cm

s.hh

s.go

v/N

PPES

/Wel

com

e.do

•

Appl

y by

pho

ne:

1-80

0-46

5-32

03 (

NPI

Tol

l-Fre

e)

Beco

me

a Q

ualif

ied

Prov

ider

Med

icar

e (f

ew w

eeks

) •

Com

plet

e pr

oces

s on

line:

ht

tp:/

/ww

w.c

ms.

gov/

Med

icar

e/Pr

ovid

er-E

nrol

lmen

t-an

d-Ce

rtifi

catio

n/M

edic

areP

rovi

derS

upEn

roll/

inde

x.ht

ml

Pr

ivat

e pa

yers

(6-

8 m

onth

s)

•As

k fo

r pr

ovid

er r

elat

ions

or

the

cred

entia

ling

depa

rtm

ent.

•

Requ

est

a cr

eden

tialin

g (e

nrol

lmen

t) p

acke

t fo

r RD

s.

•Ev

alua

te a

ltern

ativ

es.

•Co

nsid

er C

AQH

enr

ollm

ent

(Cou

ncil

for

Affo

rdab

le Q

ualit

y H

ealth

care

);

http

://w

ww

.caq

h.or

g/uc

d.ph

p

Med

icar

e M

NT

Mor

e Ba

sic

Term

s an

d Ac

rony

ms

Cod

es:

inte

rnat

iona

l/nat

iona

l num

eric

des

igna

tions

use

d to

des

crib

e:

•D

iagn

osis

cod

es (

ICD

-9)

= D

escr

ibe

an in

divi

dual

's d

isea

se o

r m

edic

al c

ondi

tion;

phy

sici

ans

and

trai

ned

bille

rs d

eter

min

e th

ese

code

s •

CP

T co

des

= C

urre

nt P

roce

dura

l Ter

min

olog

y co

des

(pro

cedu

re

code

s) t

hat

desc

ribe

the

serv

ice

perf

orm

ed/p

rovi

ded

to t

he p

atie

nt

by t

he h

ealth

care

pro

fess

iona

l •

HC

PC

S co

des

= H

ealth

care

Com

mon

Pro

cedu

re C

odin

g Sy

stem

de

velo

ped

by p

ayer

s (C

MS)

to

desc

ribe

serv

ices

whe

re n

o CP

T co

de e

xist

s •

PQ

RS

code

s =

Phy

sici

an Q

ualit

y Re

port

ing

Syst

em;

“vol

unta

ry”

qual

ity-r

epor

ting

syst

em/c

odes

; pe

nalti

es in

curr

ed fo

r no

n-pa

rtic

ipat

ion

or n

ot m

eetin

g re

port

ing

requ

irem

ents

ICD

-9 D

iagn

osis

Cod

es

(det

erm

ined

by

MD

) C

hron

ic K

idne

y D

isea

se (

CK

D)

- 58

5.X

in

clud

e a

4th

digi

t w

hich

des

crib

es t

he s

tage

of

kidn

ey d

isea

se

•585

.4;

chro

nic

kidn

ey d

isea

se, S

tage

IV

(sev

ere)

D

iabe

tes

Mel

litus

– 2

50.X

X

incl

ude

a 4t

h di

git

whi

ch in

dica

tes

the

type

of c

ompl

icat

ion,

and

in

clud

e a

5th

digi

t w

hich

indi

cate

s th

e di

abet

es t

ype

and

cont

rol

• 25

0.00

- t

ype

II o

r un

spec

ified

typ

e, w

ithou

t m

entio

n of

co

mpl

icat

ion,

not

sta

ted

as u

ncon

trol

led

•

250.

52 -

typ

e II

or

unsp

ecifi

ed t

ype,

with

oph

thal

mic

m

anife

stat

ions

, unc

ontr

olle

d

13

Com

ing

10/1

5: I

CD

-10C

M &

IC

D-1

0-P

CS

14

Tran

sitio

n to

ICD

-10

will

impa

ct a

ll bi

lling

so

ftw

are,

form

s, a

nd b

illin

g pr

oced

ures

Code

s ar

e al

pha-

num

eric

, up

to s

even

cha

ract

ers.

Fo

r ex

ampl

e:

d

iabe

tes,

typ

e 2.

.. W

ith c

ompl

icat

ion

E11.

8

chr

onic

kid

ney

dise

ase,

sta

ge I

II

N18

.3

Incl

udes

abo

ut 8

,000

cat

egor

ies

M

ore

at:

ww

w.e

atrig

htpr

o.or

g/re

sour

ces/

prac

tice/

gett

ing-

paid

15

Dia

gnos

is C

ode

Reso

urce

s

Com

pone

nts

of C

PT C

ode

Valu

es

3 co

mpo

nent

s ar

e re

view

ed t

o es

tabl

ish

a co

de v

alue

:

1)W

ork

- de

scri

bes

the

serv

ice

prov

ided

(48

.3%

)

•Pre

-ser

vice

w

ork

•

Revi

ew (

med

ical

) re

cord

s, la

b w

ork,

obt

ain

vita

ls, r

oom

set

up,

in

form

ed c

onse

nt, e

tc.

•I

ntra

-ser

vice

wor

k

•H

isto

ry a

nd p

rese

ntin

g pr

oble

m, r

evie

w o

f sy

stem

s, t

reat

men

t op

tions

, cre

ate

&/o

r di

strib

ute

educ

atio

nal m

ater

ials

, arr

ange

follo

w-

up a

nd/o

r re

ferr

al a

s ne

eded

•Pos

t –s

ervi

ce w

ork

•

Doc

umen

tatio

n, c

omm

unic

atio

n w

ith r

efer

ring

phys

icia

n, c

are

coor

dina

tion,

sho

rt-t

erm

(7d

) co

mm

unic

atio

n w

ith p

atie

nt a

s ne

eded

16

Def

initi

on o

f W

ork

17

•Tim

e leng

th o

f ser

vice

•M

enta

l Eff

ort/

Judg

men

t s

ynth

esis

of

data

/com

plex

ity o

f dec

isio

n m

akin

g •T

echn

ical

Ski

ll

know

ledg

e/sk

ills

set,

exp

erie

nce

•Phy

sica

l Eff

ort

ph

ysic

al n

atur

e of

wor

k in

volv

ed

•Psy

chol

ogic

al S

tres

s pr

essu

re t

o pr

oduc

e th

e de

sire

d ou

tcom

e an

d lik

elih

ood/

risk

of a

dver

se e

ffec

ts t

hat

may

res

ult

irres

pect

ive

of t

he le

vel o

f kn

owle

dge/

skill

/exp

erie

nce

of t

he p

rovi

der

Com

pone

nts

of C

PT C

ode

Valu

es

2) P

ract

ice

expe

nse

(47

.4%

)

in

clud

es it

ems

such

as

clin

ical

labo

r (o

ther

tha

n RD

N

wor

k), e

quip

men

t (s

cale

s, f

ood

mod

els,

nut

rient

an

alys

is s

oftw

are,

lapt

op, e

tc.)

, pat

ient

edu

catio

n m

ater

ials

, off

ice

rent

, util

ities

, per

sonn

el, e

tc.

3)

Pra

ctic

e lia

bilit

y ex

pens

e (4

.3%

)

Mal

prac

tice

insu

ranc

e –

we

pay

the

low

est

rate

s of

any

sp

ecia

lty -

$$

hund

reds

ver

sus

thou

sand

s

18

MN

T CP

T Co

des

9780

2

•M

NT

initi

al a

sses

smen

t an

d in

terv

entio

n, in

divi

dual

, fac

e-to

-fac

e, e

ach

15 m

inut

es

97

803

•M

NT,

rea

sses

smen

t an

d in

terv

entio

n, in

divi

dual

, ind

ivid

ual,

face

-to-

face

, ea

ch 1

5 m

inut

es

97

804

•M

NT,

gro

up, 2

or

mor

e in

divi

dual

s, e

ach

30 m

inut

es

CP

T co

des,

des

crip

tions

and

mat

eria

l onl

y ar

e ©

2015

Am

eric

an

Med

ical

Ass

ocia

tion.

All

Righ

ts R

eser

ved.

(s

earc

h: c

pt®

Cod

e/Re

lativ

e Va

lue

Sear

ch)

Face

-to-

Face

Tim

e/U

nit

Bille

d Fo

r an

y si

ngle

“15

min

ute

face

-to-

face

” CP

T co

de:

20

Face

to fa

ce a

ctua

l tim

e sp

ent:

1 un

it >

8

min

utes

to <

23

min

utes

2

units

> 2

3 m

inut

es to

< 3

8 m

inut

es

3 un

its >

38

min

utes

to <

53

min

utes

4

units

> 5

3 m

inut

es to

< 6

8 m

inut

es

5 un

its >

68

min

utes

to <

83

min

utes

6

units

> 8

3 m

inut

es to

< 9

8 m

inut

es

7 un

its >

98

min

utes

to <

113

min

utes

8

units

> 1

13 m

inut

es to

< 1

28 m

inut

es

Exam

ple:

15

min

utes

30

min

utes

45

min

utes

60

min

utes

/ 1

hou

r 75

min

utes

90

min

utes

/ 1

.5 h

ours

10

5 m

inut

es

120

min

utes

/ 2

hou

rs

MN

T “G

” Co

des

Hea

lthca

re C

omm

on P

roce

dure

Cod

ing

Syst

em 2

014

G02

70

•M

NT

re-a

sses

smen

t an

d su

bseq

uent

inte

rven

tion(

s)

follo

win

g 2n

d re

ferr

al in

the

sam

e ye

ar fo

r ch

ange

in

diag

nosi

s, m

edic

al c

ondi

tion

or t

reat

men

t re

gim

en

(incl

udin

g ad

ditio

nal h

ours

nee

ded

for

rena

l dis

ease

);

indi

vidu

al;

face

-to-

face

; ea

ch 1

5 m

inut

es

G

0271

•

MN

T re

-ass

essm

ent

and

subs

eque

nt

inte

rven

tion(

s)…

, gro

up (

2 or

mor

e in

divi

dual

s), e

ach

30 m

inut

es

Proc

edur

e Co

des

Appl

icab

le t

o RD

Ns

Inte

nsiv

e Be

havi

oral

The

rapy

(IB

T) fo

r O

besi

ty

22

G04

47:

Face

-to-

Face

Beh

avio

ral C

ouns

elin

g fo

r O

besi

ty, 1

5 M

inut

es

G04

43:

Face

-to-

Face

Beh

avio

ral C

ouns

elin

g fo

r O

besi

ty, G

roup

(2-

10),

30

Min

utes

IC

D-9

dia

gnos

is c

odes

for

BM

I 30

.0 k

g/m

2 or

ove

r (V

85.3

0-V8

5.39

, V8

5.41

-85

.45)

Se

rvic

e ca

n be

pro

vide

d up

to

22 t

imes

in a

12-

mon

th p

erio

d pe

r CM

S sc

hedu

le

RDN

s ca

n pr

ovid

e IB

T as

aux

iliar

y pe

rson

nel i

n pr

imar

y ca

re s

ettin

gs

RDN

s m

ust

bill

as “

inci

dent

to”

phy

sici

an s

ervi

ces

(gui

delin

es

diff

er f

or o

ffic

e-ba

sed

vs. h

ospi

tal o

utpa

tient

clin

ics)

Billa

ble

to M

edic

are;

che

ck p

rivat

e pa

yer

polic

ies

for

use

of

cod

e

Lear

n m

ore

at:

ww

w.ea

trigh

tpro

.org

/reso

urce

/pra

ctic

e/ge

tting

-pai

d/nu

ts-a

nd-b

olts

-of-

getti

ng-p

aid/

med

icar

e-pr

even

tive-

serv

ices

-obe

sity

G04

38

Annu

al w

elln

ess

visi

t; in

clud

es a

per

sona

lized

pre

vent

ion

plan

of

ser

vice

(PP

PS),

initi

al v

isit

G04

39

Annu

al w

elln

ess

visi

t; in

clud

es a

per

sona

lized

pre

vent

ion

plan

of

ser

vice

(PP

PS),

sub

sequ

ent

visi

t N

o sp

ecifi

c di

agno

sis

code

s ar

e re

quire

d, b

ut o

ne m

ust

be in

clud

ed o

n th

e cl

aim

. RD

Ns

can

prov

ide

the

AWV

unde

r di

rect

sup

ervi

sion

of

a ph

ysic

ian

(bill

as

“inc

iden

t to

” ph

ysic

ian

serv

ices

) Le

arn

mor

e at

: w

ww

.eat

right

pro.

org/

reso

urce

/pra

ctic

e/ge

ttin

g-pa

id/w

ho-p

ays-

for-

nutr

ition

-ser

vice

s/an

nual

-w

elln

ess-

visi

t-in

-med

icar

e

• • • • • • • • • •

Tele

heal

th S

ervi

ces

Und

er M

edic

are

Indi

vidu

al M

edic

are

MN

T ca

n be

pro

vide

d vi

a te

lehe

alth

U

se t

he M

NT

code

978

02 a

nd m

odifi

er “

GT”

•M

ust

use

an in

tera

ctiv

e au

dio

and

vide

o te

le-

com

mun

icat

ions

sys

tem

tha

t pe

rmits

rea

l-tim

e co

mm

unic

atio

n be

twee

n RD

N a

nd p

atie

nt

•Go

to

ww

w.e

atrig

htpr

o.or

g/re

sour

ce/p

ract

ice/

gett

ing-

paid

-in

-the

-fut

ure/

emer

ging

-hea

lth-c

are-

deliv

ery-

and-

paym

ent/

tele

heal

th f

or d

etai

ls o

n M

edic

are

M

NT

tele

heal

th

25

• • •

(Not

bill

able

to M

edic

are;

che

ck p

ayer

pol

icie

s to

det

erm

ine

use

of c

odes

)

• • • • •

• • • • • • • •

30

CPT

Code

Res

ourc

es

Med

icar

e Pe

rfor

man

ce M

easu

res:

PQ

RS C

odes

•

RDN

Med

icar

e pr

ovid

ers

can

avoi

d a

dow

nwar

d pa

ymen

t ad

just

men

t if

repo

rt o

n at

leas

t 9

mea

sure

s ac

ross

3 N

atio

nal

Qua

lity

Dom

ains

for

at le

ast

50%

of

Med

icar

e FF

S pa

tient

s.

•If

pro

vide

r se

es a

t le

ast

1 M

edic

are

patie

nt in

a fa

ce-t

o-fa

ce

enco

unte

r, m

ust

repo

rt a

t le

ast

1 cr

oss-

cutt

ing

mea

sure

(as

par

t of

th

e 9)

. •

2015

rep

ortin

g da

ta d

eter

min

es t

he d

ownw

ard

paym

ent

adju

stm

ent

(-2%

) to

be

appl

ied

in 2

017

•Pa

ymen

t in

201

5 ba

sed

on 2

013

repo

rtin

g (p

oten

tial -

1.5%

do

wnw

ard

adju

stm

ent)

•

Paym

ent

in 2

016

base

d on

201

4 re

port

ing

(pot

entia

l -2%

do

wnw

ard

adju

stm

ent)

w

ww

.eat

right

pro.

org/

reso

urce

/pra

ctic

e/ge

ttin

g-pa

id/n

uts-

and-

bolts

-of

-get

ting-

paid

Med

icar

e 20

15 P

QRS

RD

N M

easu

res

2015

PQ

RS M

easu

res

Appl

icab

le t

o RD

Ns:

PQRS

#1:

Dia

bete

s M

ellit

us:

Hem

oglo

bin

A1c

Poor

Con

trol

PQRS

#12

8: P

reve

ntiv

e Ca

re a

nd S

cree

ning

: BM

I Sc

reen

ing

and

Follo

w-u

p*

PQRS

#13

0: D

ocum

enta

tion

of C

urre

nt M

edic

atio

ns in

M

edic

al R

ecor

d*

PQRS

#18

1: E

lder

Mal

trea

tmen

t Sc

reen

and

Fol

low

-up

Plan

Q

nets

uppo

rt@

sdps

.com

*D

enot

es a

“cr

oss-

cutti

ng”

mea

sure

32

Med

icar

e Pe

rfor

man

ce M

easu

res:

PQ

RS C

odes

•

Det

ails

and

fre

e w

ebin

ar a

vaila

ble

at

ww

w.e

atrig

htpr

o.or

g/re

sour

ce/p

ract

ice/

gett

ing-

paid

/nut

s-an

d-bo

lts-o

f-ge

ttin

g-pa

id o

r ht

tp:/

/ww

w.c

ms.

gov/

Med

icar

e/Q

ualit

y-In

itiat

ives

-Pat

ient

-As

sess

men

t-In

stru

men

ts/P

QRS

/?gc

lid=

CJ3W

z5--

2b8C

FQaC

Mgo

d4m

sARg

•

PQRS

mea

sure

s an

d pr

oced

ures

upd

ated

ann

ually

•

Repo

rt P

QRS

mea

sure

s us

ing

QD

Cs (

Qua

lity

Dat

a Co

des)

Exam

ple:

30

46F

•Co

min

g in

201

8:

Valu

e M

odifi

er P

aym

ent

(tie

s PQ

RS w

ith c

ost)

The

2013

Aca

dem

y Co

ding

Sur

vey

Resu

lts

Codi

ng S

urve

y D

emog

raph

ics

Emai

l Inv

itatio

n:

Prov

isio

n of

MN

T in

Am

bula

tory

Car

e (B

illab

le)

Setti

ngs

(ACS

):

•Al

l mem

ber/

non-

mem

ber

RDN

s in

Aca

dem

y/CD

R da

taba

se;

–

Not

ret

ired

–Em

ail a

ddre

ss

–U

S re

side

nce

–To

tal E

mai

led

n =

82,

262

–To

tal R

espo

nden

ts n

= 5

,840

•

Prov

ide

&/o

r m

anag

e pr

ovis

ion

of M

NT

in A

CS n

=

3,62

8 –

Com

plet

ed e

ntire

sur

vey

n= 3

015

(~83

%)

Codi

ng S

urve

y D

emog

raph

ics:

Re

spon

se b

y Pr

actit

ione

r Ty

pe

Prac

titio

ner T

ype

Prov

ider

83%

Man

age/

Prov

12%

Man

ager

5%

Empl

oym

ent

Stat

us:

Re

spon

se b

y Pr

actit

ione

r Ty

pe

050

010

0015

0020

0025

00

IRS-

1099

W-2

Man

ager

Man

age/

Prov

Prov

ider

Prim

ary

Wor

k Se

ttin

g

Resp

onse

by

Prac

titio

ner

Type

010

020

030

040

050

060

070

080

0

Prov

ider

Man

age/

Prov

Man

ager

Mal

prac

tice

Insu

ranc

e Co

vera

ge

Resp

onse

by

Prac

titio

ner

Type

0

200

400

600

800

1000

1200

1400

Prov

ider

Man

age/

Prov

Man

ager

22.8

% o

f tot

al re

spon

dent

s do

n’t c

arry

or d

on’t

know

if th

ey c

arry

mal

prac

tice

insu

ranc

e

Med

icar

e Pr

ovid

er S

tatu

s

Resp

onse

by

Prac

titio

ner

Type

0

200

400

600

800

1000

1200

1400

Prov

ider

Man

age/

Prov

Man

ager

Yes

No

Don'

t Kno

w

Aver

age

Tim

e Sp

ent

Prov

idin

g M

NT:

Ba

sic

Serv

ices

010

020

030

040

050

060

070

080

090

0

9780

2-In

itial

9780

3 - F

/U97

804-

Gro

up

Aver

age

Tim

e Sp

ent

Prov

idin

g M

NT:

Ad

ded

Visi

ts/C

hang

e of

Con

ditio

n

0

200

400

600

800

1000

1200

G02

70-In

div

G02

71-G

roup

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

0 to

12

to 3

4 to

56

or m

ore

Mean Proportion of "Typical" Patients

Num

ber o

f Con

ditio

ns

Prov

ider

Man

ager

/Pro

vide

rM

anag

er

Com

plex

ity o

f Pa

tient

s Se

en

Resp

onse

by

Prac

titio

ner

Type

MN

T Pa

yer

Mix

Re

spon

se b

y Pr

actit

ione

r Ty

pe

020406080100

120

Prov

ider

Man

age/

Prov

Man

ager

MC

Self-

Pay

Priv

ate/

Com

mM

/A S

tate

Wel

Oth

er

PQRS

Par

ticip

atio

n

Resp

onse

by

Prac

titio

ner

Type

0

200

400

600

800

1000

1200

1400

1600

No

Answ

erYe

sN

oD

on't

know

Prov

ider

Man

age/

Prov

Man

ager

Usu

al &

Cus

tom

ary

Fee

Set

Resp

onse

by

Prac

titio

ner

Type

0

200

400

600

800

1000

1200

1400

Yes

No

Don'

t Kno

w

Prov

ider

Man

age/

Prov

Man

ager

Awar

enes

s of

Pay

er “

Caps

” by

Pra

ctiti

oner

Typ

e

0

200

400

600

800

1000

1200

1400

1600

No

Answ

erYe

sN

oD

on't

Know

Prov

ider

Man

age/

Prov

Man

ager

Sele

cted

Dis

ease

s/Co

nditi

ons

Reim

burs

ed

0.0

10.0

20.0

30.0

40.0

50.0

60.0

DMPr

e-DM

Rena

lO

besi

tyH

TNLi

pids

Percent of Respondents

Sele

cted

Con

ditio

ns R

eim

burs

ed

2006

2008

2013

Sele

cted

Dis

ease

s/Co

nditi

ons

Reim

burs

ed

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Baria

tric

Surg

ery

Failu

re to

Thriv

eEa

ting

Diso

rder

sFo

odAl

lerg

ies

GI

Diso

rder

sCe

liac

Percent of Respondents

Sele

cted

Con

ditio

ns R

eim

burs

ed

2006

2008

2013

Case

Stu

dy

A 66

yea

r ol

d fe

mal

e ha

s be

en n

ewly

di

agno

sed

with

Typ

e 2

DM

. M

D P

rogr

ess

Not

e:

Type

2 D

M, u

ncon

trol

led;

250

.02

Patie

nt r

eluc

tant

to

star

t an

othe

r m

edic

atio

n.

Refe

rral

for

MN

T, 3

vis

its

Wei

ght

: 15

5 lb

s, t

race

ede

ma

BP 1

35/7

2

H

bA1c

: 8.

4

LD

L: 1

50m

g/dl

, TG

: 27

5 m

g/dl

Case

Stu

dy

Key

item

s bi

ller

lists

on

CMS

1500

cla

ims

form

Even

if R

DN

doe

sn’t

bill

them

selv

es, y

ou s

houl

d/m

ay

need

to

prov

ide

code

s an

d in

form

atio

n in

clud

ed o

n cl

aim

– Y

OU

are

res

pons

ible

for

all s

ervi

ces

bille

d un

der

your

nam

e 1.

Com

plet

e pa

tient

con

tact

/de

mog

raph

ic

info

rmat

ion

& v

isit

docu

men

tatio

n (E

BPG

s)

2. E

nter

ICD

-9 c

ode

250.

02 o

n lin

e 21

Use

dia

gnos

is c

ode

from

the

ref

errin

g ph

ysic

ian

(PCP

); r

evie

w r

efer

ral f

orm

, MD

pre

scrip

tion,

or

call

MD

off

ice

for

diag

nost

ic (

ICD

-9)

code

.

(see

han

dout

for

sam

ple

clai

ms

form

)

Case

Stu

dy

Key

item

s to

list

on

CMS

1500

cla

ims

form

(co

nt.)

3.

Ent

er C

PT c

ode

9780

2 (in

itial

MN

T) o

n lin

e 24

d

-

List

num

ber

of M

NT

units

on

line

24g

(you

r

do

cum

enta

tion

shou

ld c

onta

in t

he n

umbe

r of

face

-to-

face

(f-2

-f)

min

utes

you

spe

nt w

ith t

he p

atie

nt

Fo

r ex

ampl

e: 6

0 m

inut

es =

4 u

nits

– b

ase

# u

nits

yo

u lis

t on

act

ual f

-2-f

tim

e sp

ent

with

pat

ient

M

odifi

ers,

if r

elev

ant

(i.e.

, Med

icar

e, T

eleh

ealth

MN

T)

-

Lis

t G

T m

odifi

er o

n lin

e 24

d in

“m

odifi

er”

colu

mn

Reim

burs

emen

t:

An A

LL M

embe

r Im

pera

tive

Sand

i Mor

ris, R

D,C

D

Indi

ana

Uni

vers

ity H

ealth

-Gos

hen

Hos

pita

l Clin

ical

Nut

ritio

n M

anag

er

IAN

D R

eim

burs

emen

t Re

pres

enta

tive

53

Your

“To

Do”

Lis

t: 1.

0 �

Prov

ide/

Bill

for

Nut

ritio

n Se

rvic

es

�M

alpr

actic

e In

sura

nce

Cove

rage

:

w

ww

.aca

dem

yper

sona

linsu

ranc

e.co

m/

�

Esta

blis

h a

Usu

al &

Cus

tom

ary

Fee

�Co

mpl

ianc

e w

ith c

urre

nt r

egul

atio

ns:

•N

PI �

HIP

PA r

equi

red

•Co

rrec

t co

ding

•

PQRS

Inc

entiv

es �

Pen

altie

s

Your

“To

Do”

Lis

t:

1.0

(con

’t)

Que

stio

ns fo

r H

ospi

tal/C

linic

Bill

ing

Dep

artm

ent

•Ar

e w

e bi

lling

for

MN

T or

nut

ritio

n se

rvic

es?

•

Wha

t in

sura

nces

are

we

in-n

etw

ork

for?

•

Are

you

awar

e th

at R

DN

s ca

n bi

ll di

rect

ly fo

r M

NT

serv

ices

? •

Are

you

awar

e th

at R

DN

s ca

n bi

ll in

clin

ic/o

ffic

e se

ttin

gs?

•Ca

n w

e ex

pand

our

ser

vice

s to

oth

er a

reas

(o

ffic

e, o

utpa

tient

, D

SMT,

clin

ics,

spe

cial

ty

prac

tices

)?

55

Your

“To

Do”

Lis

t: 2.

0

Driv

e fu

ture

EBN

P (p

ract

ice)

�

Trac

k O

utco

mes

–

Hea

lth I

mpr

ovem

ent

–Re

imbu

rsem

ent

•Pa

ymen

t ra

tes

per

Publ

ic/P

rivat

e Pa

yer

Bille

d

•D

isea

ses/

Cond

ition

s Co

vere

d •

Use

of

G-c

odes

to

prov

ide

addi

tiona

l ser

vice

(

MC

only

) �

Trac

k N

ew S

ervi

ces

Requ

ests

�

Impr

ove

Cont

ract

s N

egot

iatio

n –

Reim

burs

emen

t Ra

tes

–Ex

pand

Dis

ease

s/Co

nditi

ons

Cove

red

–Es

tabl

ish

RDN

s as

pre

ferr

ed p

rovi

ders

of

Nut

ritio

n Se

rvic

es

Your

“To

Do”

Lis

t:

3.0

�Ad

voca

te fo

r ex

pans

ion

of M

NT

bene

fit

�G

rass

root

s m

arke

ting

esse

ntia

l -

Doe

s YO

UR

heal

th p

lan

cove

r M

NT/

RDN

se

rvic

es?

-Co

ntac

t yo

ur p

erso

nal i

nsur

ance

car

rier

to d

eter

min

e nu

triti

on s

ervi

ces

cove

rage

-

Com

mun

icat

e w

ith y

our

faci

lity

to s

ee if

you

are

bi

lling

for

outp

atie

nt n

utrit

ion

serv

ices

(M

NT)

-

Med

ical

pro

fess

iona

ls a

skin

g fo

r RD

N s

ervi

ces

but

unaw

are

of

how

to

pay

for

serv

ices

-

Man

y fa

cilit

ies

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Academy of Nutrition and Dietetics, Revised January 2012

Coding, Coverage, Compensation for MNT Academy Coding and Coverage Committee

To successfully bill for nutrition services provided by RDs, practitioners need to become familiar with certain terms and procedures used on claims forms.

Definitions Codes –The standardized “language” used to describe the particular service provided (e.g. MNT) and the reason the service was necessary (e.g. the disease/condition addressed). Both the procedure and diagnosis codes are used on claims so that a decision can be made for reimbursement of the service. Current Procedural Terminology (CPT) codes- A medical code set used to identify and describe the services offered by all health care providers to the public. The CPT codes provide a uniform language to accurately describe medical, surgical and diagnostic services and allow nationwide communication among providers, patients and third party payers. Each code is comprised of five-digit numbers, eg. 97802. These codes are categorized into one of six major sections (i.e. Evaluation & Management, Anesthesiology, Surgery, Radiology, Pathology and Lab, or Medicine.) The MNT CPT codes are listed in the Medicine section. Within each of the six sections, the codes are divided into further subsections such as body systems (musculoskeletal, respiratory, etc), place of service (office visit or hospital visit) and the patient’s status (new or established patient). The CPT code set is maintained, annually updated and copyrighted by the American Medical Association (AMA), and has been adopted by the Secretary of Health and Human Services as the standard (under the Health Insurance Portability and Accountability Act-HIPAA) for reporting health care services in the US. (Source: The AMA CPT 2012, and CMS Glossary accessed from http://www.cms.gov/apps/glossary/default.asp?Letter=C&Language=English.) Healthcare Common Procedure Coding System (HCPCS)- Medicare’s National Level II Codes- A medical code set, accepted under HIPAA, that identifies health care procedures, equipment, and supplies for claim submission purposes. HCPCS Level II codes are alphanumeric codes, eg. G0270, used to identify various items and services that are not included in the CPT code set. CMS annually maintains the codes with input from other payer groups. HCPCS codes include two G codes used with Medicare Part B Medical Nutrition Therapy (G0270 and G0271) and codes for Medicare diabetes self-management training programs (G0108 and G0109). (Source: CMS’ Web page: http://www.cms.hhs.gov/apps/glossary/.) ICD-9-CM codes (International Classification of Diseases - 9- Clinical Modification) Often referred to as “diagnosis codes,” this code set is the official system for tracking disease/condition incidence in all health care settings in the US. The National Center for Health Statistics (NCHS) and CMS are the governmental agencies responsible for overseeing the ICD-9-CM. Diagnosis codes describe an individual’s medical condition that is determined by the treating physician. By law, CMS requires physicians to submit diagnosis codes for Medicare reimbursement. Physicians are the trained health care provider responsible for determining a medical diagnosis, so when listing the diagnosis code on a claim form for nutrition services provided by an RD, the RD should obtain the appropriate diagnosis code(s) from the patient/client’s physician. An example of a diagnosis code is 250.02- diabetes mellitus, type II or unspecified type, uncontrolled. Note: A new code set, ICD-10-CM, will replace the current ICD-9-CM codes effective October 1, 2013. (Source: AMA International Classification of Diseases; Physician ICD-9-CM 2012 & CMS Glossary: http://www.cms.hhs.gov/apps/glossary/default.asp?Letter=I&Language=English#Content.) NPI- The National Provider Identifier (NPI) is a unique, government issued, standard identifier mandated by HIPAA that replaces providers’ other provider numbers from Medicare and other private payers. Once assigned, the 10 digit numeric NPI stays with a provider for life. For more information go to the Academy’s Web page at: www.eatright.org/coverage.

Academy of Nutrition and Dietetics, Revised January 2012

Coding, Coverage, Compensation for MNT--CPT and HCPCS Codes Relevant to Nutrition Services Academy Coding and Coverage Committee Medical Nutrition Therapy (MNT) CPT and HCPCS codes Compared with other CPT codes, the following MNT CPT codes best describe the services that RDs provide to patients/clients receiving medical nutrition therapy services for a particular disease or condition. The codes can be used among private insurance companies, depending on the coding and billing details listed in the RD’s contract with the payer. CMS requires use of these codes for the Medicare Part B MNT benefit by enrolled RD providers who perform MNT services for diabetes, non-dialysis kidney disease and kidney transplants.

97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (2 or more individual(s)), each 30 minutes CPT codes, descriptions and material only are copyright @2012 American Medical Association. All Rights Reserved.

CMS also established HCPCS codes for use with Medicare covered services, effective for dates of service on or after January 1, 2003. These new G codes should be used when additional hours of MNT services are performed beyond the number of hours typically covered, (3 hours in the initial calendar year, and 2 follow-up hours in subsequent years with a physician referral) when the treating physician determines there is a change of diagnosis or medical condition that makes a change in diet necessary.

G0270 Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes. G0271 Medical Nutrition Therapy; reassessment and subsequent interventions(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (2 or more individuals), each 30 minutes. Source: Center’s for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, Chapter 4- Part B Hospital, accessible at: http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

Other CPT codes for RDs-Private insurance payers, but not Medicare, may accept other CPT codes, such as the Education and Training codes (98960-62); Medical Team Conference (99366 and 99368); Telephone Services (98966-68); and On-line Medical Evaluation – (98969). Check your payer contract, policies or call the payer provider relations for more code policies. Physicians who offer RD provided nutrition services at their clinics may be able to bill certain third private insurance companies (NOT Medicare Part B) as “incident to” physician’s services. For additional “incident to” details go to “providing the service & billing” at www.eatright.org/mnt; for other code details go to www.eatright.org/coverage. Diabetes Self-Management Training (DSMT). Medicare Part B covers diabetes self-management training (DSMT) services when these services are furnished by a certified provider at an accredited program. Other private payers may also cover DSMT. This program is intended to educate beneficiaries in the successful self-management of diabetes and includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan (as indicated); and motivation for patients to use the skills for self-management. The following HCPCS codes are used for DSMT:

G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes. G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes. Source: CMS Medicare Benefit Policy Manual, Chapter 15 accessible at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

Academy of Nutrition and Dietetics, Revised January 2012

Coding, Coverage, Compensation for MNT; ADA Billing Primer – Frequently Asked Billing Questions; Academy Coding and Coverage Committee What information is typically included on the claims form?

• The name of the insured policy holder, and the patient/client name, gender, address, phone number, date of birth, social security number

• Name of the patient’s insurance, the individual insurance number and group number • CPT code and number of code units for the provider’s service, eg. RD uses MNT codes • ICD-9-CM code (from referring physician) • Referring MD name and NPI; and RD provider name and NPI • Date of service and charge for the service • Signature date (Signature on File)

What is involved with hiring a biller to handle claims for nutrition services? RDs may find it helpful and time/cost-effective to hire a biller to handle claims for nutrition services. Billers are familiar with the various claims forms, codes and billing procedures for third party payers. Billers usually are paid based on the volume of the practice, so a biller can get anywhere from 4 to 7% of the RD’s payments. Although there are several national groups that provide billing services and resources (see “Billing Information” resources on the Academy’s Web page: www.eatright.org/coverage), talking to local private practice RDs or physicians can be a great source for identifying a local biller. Or, consult your local Yellow Pages (look up “Medical Billers”) or conduct your own Internet search (query “medical billing”) to identify billers in your area. What claims forms are used to bill for nutrition services? The CMS1500 and CMS1450 (UB-04) forms are accepted by Medicare, however for Part B (outpatient) services, claims for MNT provided by enrolled RDs are usually submitted on the CMS1500 form. Some hospitals may only have access to the CMS1450, typically used to bill for Medicare Part A (inpatient) services, however in these cases, CMS will accept the CMS1450 form for Medicare Part B outpatient MNT services. Many private insurance companies use the CMS1500 form. For more information on the CMS1500 form, go to the Academy’s Web page at www.eatright.org/mnt, then click on “providing the service & billing” and then “forms”. If the client/patient is self-paying for the nutrition services, and the RD is not filing a claim with an insurance company, a Superbill is manually completed by the RD and provided to the client/patient. A Superbill is a pre-printed, or created form that itemizes and describes the services and fees provided to the patient/client. For information on Superbills go to www.eatright.org/coverage, then “presentations.” What other resources does the Academy have to help me successfully code and bill for nutrition services? Articles on setting fees: Duester, J., Michael, P.; Myers E. Tips for Contract Negotiations and Establishing MNT Rates. J AM Diet Assoc. 2001; 101 (6): 624-626.

Duester, J; Building your Business-Setting Your Fees: A Cost-Based Approach. J AM Diet Assoc., 1997; 97, Issue 10, Supplement: S129-S130.

Dietetic Practice Group (DPG) resources: Many DPGs have resources available to their members, check their web page for information. For example, the Nutrition Entrepreneurs (NE) DPG has a mentoring program where RD members can contact another DPG member for discussion/networking etc. For more information visit the NE web site at www.nedpg.org.

Making Nutrition Your Business. An essential resource for any dietetics professional considering a switch to private practice, consulting, writing, or speaking. Available at www.eatright.org/shop. Access Medicare and other Coding and Coverage Information in the Members Section of the Academy’s Web site; www.eatright.org/mnt and www.eatright.org/coverage.

• Medicare MNT Resources HIPAA and Compliance Resources

Academy of Nutrition and Dietetics, Revised January 2012

• Private Insurance & Employers Resources The MNT Works Kit & List of Educational Sessions

• Academy Reimbursement Representatives’ Contact Information (for the affiliates and DPGs)

The medical nutrition therapy (MNT) CPT codes are used by many third party payers, including Medicare. These codes best describe the MNT services that registered dietitians provide to patients.

97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.

97803 reassessment and intervention, individual, face-to-face with the patient, each 15 minutes.

97804 group (2 or more individual(s)), each 30 minutes.

Additional Codes Used by RDs (refer to CPT book for full code description): G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second

referral in same year for change in diagnosis, medical condition, or treatment regimen, individual, face-to-face with the patient, each 15 minutes.

G0271 group (2 or more individual(s)), each 30 minutes.

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes.

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.

98960–98962 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family).

98966–98968 Telephone assessment and management service provided by a qualified nonphysician health care professional.

98969 Online assessment and management service provided by a qualified nonphysician health care professional, internet or electronic communications.

99071 Educational supplies, such as books, tapes, and pamphlets, provided by the physician (or other qualified health care professional) for the patient’s education at cost to physician.

99366 and 99368 Medical team conference, with and without the patient and/or family.

CPT codes, descriptions and material only are copyright ©2009 American Medical Association. All Rights Reserved.

Frequently Used Codes for Nutrition Services

Medical Nutrition Therapy

MNTWorks